Objectives: 1. To find out the % of users and nonusers of contraception. 2. To calculate the unmet need of the community. 3. To find the knowledge index of the study group. 4. To find out the factors assoicated with the nonusage of contraception.
Study Design: Community based Cross-sectional study.
Setting: Slum clusters in urban Delhi.
Study subjects: Married eligible women of 15-45 years. Sample size : 243 married women.
Study variables: Acceptors, Non-acceptors, Type of method, Pregnant & non pregnant women, Intented, mistimed and unwanted pregnancy.
Outcome variables: Unmet Need, Knowledge Index and Reasons.
Statistical variables: Percentage, Z-test.
Results: Mean age of study subjects 29.7 + 2.9 yrs. 34.6% of the study subjects were users, where tubectomy accounted for 58.3%. Vasectomy as a method was not found accepted by any of subject's partner. Of 159 women not using contraception 22.6% women had the need for spacing and 27.2% women had unmet need for limiting. Thus the total of 49.8% women had unmet Need of contraception. In majority of women opposition from husband's/families (30.6%) and male child preference was cited as the main reason for non use of contraception. (Z=2.88, p<0.001). 60.3% of women had Knowledge Index of 3 or more i.e. despite sufficient knowledge, study subjects had a high level of unmet need.
Key words: Unmet need, Contraception
Since the 1960's, survey data have indicated that substantial proporations of women wanted to stop or delay child bearing but are not practicing contraception. This discrepancy is referred to as the 'unmet need' for contraception. There are over 120 million women in developing countries, including 35 million in India, who would prefer to avoid becoming pregnant, either right away or ever, but they are not using contraception (1). The concept of unmet need points to the gap between these women's reproductive intentions and contraceptive behaviour. In doing so, it poses a challenge to family planning programme of reaching and serving millions of women whose reproductive attitude resemble those of contraceptive users but who, for some reason or combination of reasons, are not using contraception (2).
Among the common reasons for unmet need are difficulty with access to and quality of family planning services, health concerns about contraceptive and side effects, large family or male child preference, opposition from husbands/families. By responding to these concerns of women with unmet need, programmes can serve more people and in a better way.
In view of the above, the present study was carried out with the objective of finding out the unmet need and the factors associated with non usage of contraceptive methods.
The study was undertaken in the clusters near Maulana Azad Medical College, New Delhi, India. Study was community based cross-sectional conducted in September 1999. Initial enumeration identified a total of 750 households in the cluster, of which 365 households were selected using systematic random sampling technique. Total number of married women eligible for the study were found to be 243. These women were interviewed to screen out the unmet need group. Criteria used for identification of unmet need group included (a) all fecund women who were married and presumed to be sexually active and were are not using any method of contraception, and/or (b) who either did not want to have any more children and/or (c) wanted to postpone their next birth for at least two more years. The unmet need group also included all those pregnant and lactating mothers whose current or previous pregnancies were unintended or mistimed.
A female doctor interviewed the participants using a pretested questionnaire. Information on demographic, socio-economic factors, pattern of contraceptive use in the study group and the reasons for not using contraception in the "Unmet need group" was collected. "Knowledge Index" was created using three items :
(a) Mentioning a modern contraceptive method without being prompted
(b) Being aware of its source
(c) Having right knowledge of about side effects.
This index was used to judge the knowledge level of the study women. Score of 3 or less indicated poor knowledge and Knowledge Index score of more than 3 indicated sufficient knowledge regarding modern contraceptive methods.
Results: Mean age of the 243 study subjects was found to be 29.7+2.9 yrs. and average number of children per women was 2.9. Among the current acceptors of contraception, tubectomy accounted for 58.3%. Vasectomy as a terminal method was not found to be accepted by any of subject partner. 11.9% were using oral contraceptive, 8.3% an intrauterine device, 14.3% condoms and only 2.4% were using injectable as method of contraception. 4.8% of current users were using traditional methods of contraception.
Of 243 surveyed women 65.4% (159) of them were not using any form of contraception presently. In the present survey 9.0% of study women were found to be pregnant (22/159). 68.2% of these pregnant women had unmet need because 45.5% had mistimed the present pregnancy and in 22.7% the present pregnancy was unwanted. Among 56.4% (137) non-pregnant women not using contraception, 6.6% reported to be infertile. Among these non-pregnant fertile women, 35.2% (45) wanted more children but not before two years and 47.7% (61) wanted no more children. Of 159 women not using contraception 22.6% women (55) felt the need for spacing and 27.2% (66) women had the need for limiting children. Thus a total of 49.8% (121) women were identified to have unmet need of contraception in the study group.
Most of the unmet need among younger women is for spacing births, because younger women still want to have more children. In the present study women of 15-19 years had highest unmet need for spacing (100%). This finding suggests that these women have already borne at least one child at such an early age and despite a need for spacing none was using any form of contraception. These adolescent women group intend to use contraception and therefore our family welfare programmes specially needs to address the family attitudes of these women.
Among the older women most unmet need is for limiting births because older women have had as many children as they want to, often more (18). In the present study highest unmet of limiting family size was present in 40-45 years aged women. Contraceptive use pattern was highest for age 35-39 years followed by 30-34 years where predominant mode used was tubectomy. (Table 1).
In majority of women opposition from husband's/families (30.6%) and male child preference (19.8%) was cited as the main reason for non-acceptance of any contraception. In present study 19.8% of respondents cited large family or male child preference as the reason for non-acceptance of any contraceptive method. The desired family size in the study was found to be 3, with two sons and one daughter. In case of 18.2% of mothers, health concern about contraceptive and side effects were responsible for unmet need. Difficulty with access to and quality of family planning services, and lack of information was reported by 8.2% and 5.8% of mothers as reason for non-use of contraception. In case of 9.1% of mothers, little perceived risk of pregnancy were responsible for unmet need. They thought that they were uncertain about child bearing and so were not interested in contraception. They reported rarely having sexual relations, or considered themselves to be too old to conceive. In 3.3% of mothers, the reasons for unmet need was that, they wanted to complete family and then adopt sterilization. In 2.5% of mothers dissatisfaction with the health services were responsible for unmet need. Majority of them complained of poor quality of service as the main reason of dissatisfaction. In case of 2.5% mothers religions taboos were responsible for the unmet need. The study community had Hindu Muslim ratio of 60:40. Among the various reasons, opposition from husband/families was the number one reason cited by women with unmet need for limiting. For women with need for spacing, health concerns for contraceptive and side effects was the major reason for non-use of any contraceptive method. The difference amongst the reasons reported by the women of these two groups, opposition from husbands/families and completion of family before sterilization was found to be statistically significant (z=2.88 p<0.001 & z = 2.08 p < 0.05 respectively).
Various studies indicate that along other reasons, lack of sufficient knowledge may contribute to more than two-thirds of all unmet need (3). In our study 47.1% of women reported knowing 2-3 methods of contraception without being prompted and 61.2% were aware of its source. But only 25.6% of women had the right knowledge about their side effects, 60.3% of women with unmet need could mention one or more method, identify its source and discuss its side effects. Our study reveals despite sufficient knowledge these women had high level of unmet need.
More married women with unmet need live in India than in any other country-about 31 million. Among surveyed countries, levels of unmet need, as a percentage of all married women of reproductive age range from 11% in Thailand and Turkey to 36% in Kenya and 37% in Rwanda. In developing countries average level of unmet need is about 20% (4).
About 85% of contraceptive users in India are women. Moreover among the users of terminal methods in India, 97.2% are women (5). In India desired family size of most couples is 3 or more children according to Khan and Gupta (6) and Rajaretnam and Deshpande (7).
As shown by the present study, husband's objection has strong impact on contraceptive use by his partner, it is therefore essential to focus on programmes addressing reproductive health needs and perceptions of men in reproductive matters. Nag noted that a woman may have unmet need for family planning because of high social cost of challenging the opposition from spouse or anyone else in her social influence group (8). Rama et al noted in 12% of mothers, the reason for unmet need was opposition from husband, families and communities (9). Because most of the family planning programs are designed to serve primarily women, the finding of husband approval or disapproval has important program implications. In Uttar Pradesh a study found that little interest in contraception was being met because the family welfare programme gave little attention to temporary methods such as oral contraceptives (10). In a peri urban community of Tamil Nadu, unmet need often resulted from the lack of contraceptive choices, sterilization being the only method available (11).
The present study emphasizes the need to develop programmes to target men explicitly. Increased involvement of men in reproductive health of the family is appreciated by their partners and a large number of women are motivated to control fertility (12,13). Experiences show that attitudes can be changed. In India, studies show that men will also accept vasectomy when conditions for service and delivery are favourable despite poverty, patriarchal traditions, and preference for sons. (14)
The reproductive health programmes should (i) encourage men to have better communication with their partners so as to decide mutually the reproductive health issues including method of contraception (ii) help narrow gender gap (iii) dispel the misbelief that empower women is a treat to them in any manner (iv) provide sexual and reproductive health information and services to men to prevent unintended pregnancies and STDs.
Focussing programmes on increasing male involvement does not imply that the family welfare programmes should now completely shift their focus on men. Simultaneous efforts to further improve the services and quality of care for women must go on.
As more than third of women lacked information about contraceptive methods (34.7%) and also had conerns about the side effects based on incorrect information (73.4%), emphasis should be made on communication and good counselling to the women, giving correct information about availability, source, side effect etc. of contraceptive methods. Lastly, good quality services and access to convenient methods are important to meet unmet need.
Department of Preventive & Social Medicine,
Maulana Azad Medical College,
New Delhi (INDIA)